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SoDM Masters Theses
School of Dental Medicine
June 2001
Patient Self-Reported Satisfaction with Maxillary
Anterior Dental Implant Treatment.
Anna Levi
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Levi, Anna, "Patient Self-Reported Satisfaction with Maxillary Anterior Dental Implant Treatment." (2001). SoDM Masters Theses. 78.
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PATIENT SELF-REPORTED SATISFACTION WITH
MAXILLARY ANTERIOR DENTAL IMPLANT TREATMENT
Anna Levi
DDS, University of Athens, School of Dental Medicine, 1997
A Thesis
Submitted in Partial Fulfillment of the
Requirements for the Degree of
Master of Dental Science
at the
University of Connecticut
2001
APPROVAL PAGE
Master of Dental Science Thesis
PATIENT SELF-REPORTED SATISFACTION WITH MAXILLARY
ANTERIOR DENTAL IMPLANT TREATMENT
Presented by
Anna Levi, DDS
Major Advisor
Jhn R. Agar
Associate Advisor
Walter J. P.,so
r
.
Associate Advisor
Susan T. Reisine
-
ThOmas D. Taylor
University of Connecticut
2001
ACKNOWLEDGEMENTS
I would like to thank Dr. John Agar for giving me the opportunity to be a resident
in this graduate prosthodontic program. His confidence in my abilities and advice
throughout this project were invaluable. I would also like to thank Dr. Agar for
facilitating this research project during my prosthodontic residency program and
acknowledge his tremendous contributions to my clinical training, while working on this
research. Also, his critical review of the thesis is greatly appreciated.
I would also like to thank my advisors, Dr. Susan Reisine and Dr. Thomas Taylor.
Their individual contributions are greatly appreciated. The editorial comments from both
Dr. Reisine and Dr. Taylor were insightful and helped in refining the final text.
I would like to express my most sincere gratitude to Dr. Psoter for his ideas,
guidance and constant support in all aspects of this project.
I am grateful for the valuable
time he spent with me discussing experimental design and statistical analysis and also for
his patience, friendship and for his great sense of humor.
I would like to thank Mr. Richard Feinn for his enthusiastic assistance on the
statistical analysis performed in this investigation.
I also wish to acknowledge the work of Dr. Ralph V. Katz in developing the
questionnaire used in this project. I would like to thank Dr. Katz for his initial direction
and evaluation of the research as it progressed.
iii
DEDICATION
This work is dedicated to my family and friends who gave me strength and helped
me believe in myself and go after my dreams.
Without their guidance and support, none of this would have been possible.
iv
TABLE OF CONTENTS
Chapter
List of Tables
Page
viii
List of Appendices
x
Introduction
1
Literature v,evlew
2
Specific Objectives
7
Immediate Research Goals
7
Null Hypotheses
8
Methods and Materials
11
Study Design
11
Sample selection
11
Questionnaire
14
Dental Record Review
15
Statistical Analysis
16
17
Results
Descriptive Characteristics
17
Comparison between subjects and non-respondents
18
Patient satisfaction
19
Specific aspects of dental implant treatment not related to overall
20
satisfaction
Techni6al aspects and dimensions of treatment bivariately related to overall
22
satisfaction
Multivariate analysis
23
Ranking
24
Reliability/Validity issues
25
27
Discussion
27
Overall patient satisfaction
Demographic variables, technical aspects and dimensions of scale
28
not related to overall satisfaction
Technical aspects and dimensions of scale bivariately related
to patient overall satisfaction
31
Multivariate analysis
34
Ranking
36
Limitations
38
vi
Furore Research
39
Conclusions
40
Tables
42
Appendices
61
Bibliography
82
vii
LIST OF TABLES
Table
Page
Title
List of items that appear in self-administered mailed questionnaire
42
List of variables that appear in the dental record data abstraction form
43
Demographic characteristics of subjects
44
Test for difference between participants and non-participants
45
Response distribution to questionnaire items on patient satisfaction
46
Cross-tabs with p-values, as determined by Fisher’s exact testing, for the
dichotomized dependent variable (overall satisfaction) and the dichotomized
independent variables, with the corresponding numbers as the items appear
in the self-administered mailed questionnaire
49
Cross-tabs with p-values, as determined by Fisher’s exact testing, for the
dichotomized dependent variable (overall satisfaction) and the dichotomized
independent variables, with the corresponding numbers as the items appear in
the dental record data abstraction form
viii
52
Questionnaire and dental record variables that were not related to
54
patient overall satisfaction (p>0.05)
Bivariate odds ratios and CI’s of questionnaire variables that were related to
patient overall satisfaction as determined by Fisher’s exact testing at a
10.
statistically significant level p<0.05
55
Final multivariate logistic regression model for overall satisfaction
56
Final multivariate logistic regression model, after controlling
57
for age and gender
Q 13-Reasons to select dental implant over other alternatives
58
prior to treatment
13. Q12-Trade off; would rather compromise appearance vs. function
59
Chi-square analysis and measure of agreement (kappa) between the two
variables examining complications. Q 11, which was derived from the
questionnaire, describes what the subjects perceived as a complication,
whereas A19 is data about complications, as abstracted by AL
60
from the dental records
ix
LIST OF APPENDICES
Appendix
Title
Page
A. Measure of dental patient satisfaction
61
B. Procedure codes used to identify potential subjects
62
C. Cover letter, which accompanied questionnaire
during the first mailing
63
D. Introductory letter sent by the Director of the Graduate Prosthodontic
Program
65
E.
Self-administered mailed questionnaire
66
F.
Cover letter, which accompanied questionnaire, during the second
mailing
75
G. Dental record review data abstraction form
77
H.
81
Siebert’s classification o.f ridge defects
INTRODUCTION
Dental implants have been shown to be a solution that is predictable, moderately
trouble-free and impressively successful, in terms of implant survival, for the treatment of
partial and complete edentulism, as judged by clinicians from a biologic standpoint
-.
This should not lead to the assumption that implants are necessarily the best treatment
modality for the replacement of missing teeth for all patients
It has been suggested that the impact of implant treatment outcome should be
additionally evaluated by the treatment in terms of patients’ satisfaction9. Patient-based
assessment of the outcome of treatment has been extensively used in the dental literature
to evaluate the benefit of implant-supported overdentures and their perceived advantages
compared to conventional complete dentures
-. However,
there, are few articles in the
implant literature concerning patient satisfaction with fixed prosthodontic treatment in the
maxilla 9-2, where patient
dissatisfaction
has been reported to be as high as 17%, one
third of which was particularly attributed to esthetic problems 2.
Moreover, it has been
demonstrated that esthetic preferences are different when evaluated by patients, than
those evaluated by dentists2223’ 24.
LITERATURE REVIEW
Dental implant treatment "success" has been judged retrospectively in terms of
implant survival, which is based on biologic criteria or in terms of prosthetic restoration
survival and this success has been reported to be as high as 96% 2’25. Clinical data
collected retrospectively from implant patient recall examinations -’ 26-27 have identified
some of the problems that have occurred, such as difficulty with speech, soft tissue
reactions, prosthesis fracture, gold screw fracture, lip and cheek biting.
Those
complications do not preclude the prostheses from being considered "successful", as long
as they remain in function, the dental implants have not been removed and no signs of
infection, mobility or radiographic radiolucency are detected9.
This high success rate defined by clinical and biological criteria may not
necessarily reflect patients’ satisfaction with the outcome of their treatment. The impact
of dental implant treatment on quality of life (QOL) has been discussed extensively in the
literature a,
28-30.
The judgment of QOL is made by considering broad areas of life
experiences that include physical, psychological, economic and social domains and the
best judges of these are the patients themselves 28. It has been stated that it is important to
use quality of life measures, particularly when the conditions that are being studied are
not life threatening and the treatment options may vary 18 (i.e., surgical vs. non-surgical
treatment, implants vs. fixed or removable partial denture). Locker
concluded in a
literature review on patient-based assessments of implant therapy that outcome measures
need to be more carefully selected so as to reflect patients’ concerns, rather than
biological criteria.
Zarb et al. published an editorial article about optimizing treatment outcomes for
dental implants. These authors reported on the proceedings of the Toronto Symposium,
held at the University of Ontario, Canada, in 1998, where the participants concluded that
patient satisfaction is a factor that should be included in the criteria of success of dental
implants. More specifically, it was proposed that all future implant research should
include patient-based outcomes that reflect degrees of satisfaction with treatment, quality
of life, oral health status, selected morbidities and economic impact9.
Patient-based assessment of treatment outcome has been reported in the complete
denture prosthodontic literature 3-33 Researchers have evaluated patient satisfaction with
complete dentures and masticatory performance and found that there is an association
between improved oral function and patients’ self-esteem3-33 Patients’ perceptions have
also been used for the assessment of the treatment outcome of mandibular overdentures.
The overall benefit of using implants for the improvement of complete dentures in the
treatment of the edentulous mandible, as perceived by patients, has been investigated in a
series of studies, where the subjects were asked to evaluate various aspects of their
4
treatment, such as oral function, comfort, oral health and esthetic appearance -s’ 34-35.
Locker reviewed 19 articles on this subject with a variety of study types and outcome
measures.
Those studies included measures of denture satisfaction, such as self-
perceived chewing ability and personality, self-esteem, body image, psychologic and
social well-being assessments. The author found that there was little consensus as to
what was being measured or how the measurements were made. He concluded that
future studies should be designed in a way that outcome measures better reflect patients’
concerns.
The development and validation of scales used to measure patient satisfaction
with health care services is a common subject in the medical 64s and dental 94 literature.
Davies et al. 39 described the development of a 19-item self-administered dental
satisfaction questionnaire in which 5 scales where constructed utilizing factor analysis.
The defined scales were 1) access, 2) availability/convenience, 3) cost, 4) pain and
5) quality of care, representing major sources of satisfaction and dissatisfaction with
dental care providers and services. Chapko et al. 4 developed and validated a 42-item
instrument to measure dental patient satisfaction, which comprised 13 subscales to be
subsequently used as a method of obtaining feedback on patient satisfaction with demal
care in general (appendix A).
Few surveys have been conducted regarding patient satisfaction with dental
implant treatment in reference to maxillary fixed restorations 9-21’ 23 In a follow-up study
of maxillary and mandibular implant restorations, where patients were recalled to record
problems and complications, the rate of dissatisfaction with implant prostheses was 17%,
one third of which was particularly related to esthetics 2. Only one study 2
(N=39) has
investigated patient-satisfaction specifically with maxillary anterior teeth and compared
patients’ and specialists’ opinions about the esthetic result. The subjects of this study
were asked to assess the appearance of their implant crown, the harmony with the natural
teeth, the appearance when they smiled, as well as to evaluate several technical issues,
such as crown form and color. This study suggested that patients and prosthodontists
disagree as to what each considers as being of primary importance in achieving optimal
esthetic results.
Satisfaction with the esthetic result is an important determinant of the patients’
overall satisfaction with dental implant treatment2’
s. The most obvious area in which to
judge esthetics is the maxillary anterior region, which is socially critical, being
particularly visible to the patient and others. Since the criteria for assessing the quality of
the esthetic result are subjective, it is imperative to inquire about the patients’ opinion,
which may differ from that of the clinician, in order to ensure patient satisfaction24.
The purpose of this study was to examine whether there is an association between
overall satisfaction with demal implam treatmem and:
1. patient perceptions of selected technical aspects of treatment outcome,
2. patient perceptions of treatment experience,
3. clinical variables related to dental implant treatment, as abstracted from the
dental records,
4. patient demographic characteristics.
SPECIFIC OBJECTIVES
An objective of this study is to develop an instrument, which may be used in
future research in the investigation of patient satisfaction with dental implant treatment.
This instrument was used in this study to assess the degree of patient satisfaction with the
prosthetic treatment. The specific objectives of this study are to examine whether there is.
an association between overall satisfaction and:
1. patient perceptions of specific technical aspects of treatment outcome e.g. appearance,
function, oral health,
2. patient perceptions of treatment experience e.g. cost and time until completion of
treatment, satisfaction with treating doctor,
3. clinical variables related to dental implant treatment, as abstracted from the dental
records e.g. complications, length of treatment,
4. patient demographic characteristics, such as age, gender, socioeconomic status.
IMMEDIATE RESEARCH GOALS
The purpose of this study is to examine how the specific sub dimensions of the
scale (i.e. various technical patient-perceived factors and demographic characteristics)
correlate with overall patient satisfaction. The findings of this study may be directly
applied in clinical practice as a means of understanding patient values and expectations
from dental implant care.
Practitioners who treat patients with dental implants must be familiar with
potential areas of dissatisfaction. Better understanding of factors, which affect patient
satisfaction, may help them achieve more successful results by proactively addressing
patient needs and desires. Considering patient perception of "success" may enhance
dentist-patient rapport and assist the dentist in being more effective in the treatment
provided. Clinicians may be better prepared to discuss treatment limitations with patients
and to explore alternative means of treatment, if appropriate, which may provide superior
satisfaction for them, by considering patient perspective during the initial treatment
planning phase.
This patient-dentist communication process may then continue
throughout the treatment phase.
NULL HYPOTHESES
There is no difference in patient self-reported overall satisfaction with
maxillary anterior dental implant treatment between subjects highly and less than.highly
satisfied with specific technical aspects of the treatment outcome. This null hypothesis is
applied to patients who received maxillary anterior dental implants and associated fixed
restorations, provided by University of Connecticut Health Center (UCHC) Advanced
Education of General Dentistry (AEGD) or Prosthodontic (Pros) residents or faculty,
during the period January 1988 to July 2000. Those aspects include the following: a.
appearance of the implant restoration (shape, position, color), b. appearance of the
gingiva (metal showing through the gingiva, gingival recession, loss of interdental
papilla), c. overall appearance of the implant restoration when smiling, d. function
(speech, chewing capacity, comfort), e. oral health (ability to clean, freshness of breath,
gingival inflammation).
There is no difference in patient self-reported overall satisfaction with
maxillary anterior dental implant treatment between subjects highly and less than highly
satisfied with the treatment experience e.g. cost and time until completion of treatment,
information received about dental implams prior to treatment, satisfaction with treating
doctor. This null hypothesis is applied to patients who received maxillary anterior dental
implants and associated fixed restorations, provided by UCHC AEGD or Pros residents
or faculty, during the period January 1988 to July 2000.
There is no relationship between patient self-reported overall satisfaction
with maxillary anterior dental implant treatment and clinical variables related to dental
implant treatment, as abstracted from the dental records e.g. type of implant places,
complications, previously failed dental implants, position of the missing tooth replaced
by the implant, proximity of the implant restoration with other restored teeth, number of
10
missing teeth, grafting procedures. This null hypothesis is applied to patients who
received maxillary anterior dental implants and associated fixed restorations, provided by
UCHC AEGD or Pros residents or faculty, during the period January 1988 to July 2000.
There is no relationship between patient self-reported overall satisfaction
with maxillary anterior dental implant treatment and patient demographic characteristics,
such as age, gender, marital status, annual income, education level. This null hypothesis
is applied to patients who received maxillary anterior dental implants and associated
fixed restorations, provided by UCHC AEGD or Pros residents or faculty, during the
period January 1988 to July 2000.
METHODS AND MATERIALS
Study Design
This project, investigating patient satisfaction with dental implants, was a cross
sectional study of patients who were treated with dental implants and received associated
fixed restorations on maxillary anterior teeth, provided by University of Connecticut
Health Center (UCHC) Advanced Education in General Dentistry (AEGD) or
Prosthodontic (Pros) residents or faculty, during the period January 1988 to July 2000.
The research protocol was reviewed and approved by .the University of
Connecticut Health Center Institutional Review Board (IRB). The eligible patients were
mailed a cover letter, which accompanied the mailed questionnaire and served the
purpose of an informed consent (appendix C).
Sample Selection
The study population consisted of all patients who had been treated with at least
one dental implant in the area of teeth # 4-13 (maxillary central and lateral incisors,
canines and first and second premolar teeth) and who had received the final fixed
prosthetic restoration, provided by UCHC AEGD or Pros residents or faculty during the
period January 1988 through July 2000 and that was present in the mouth at the time of
the subjects’ recmitmem (May to August 2000).
11
12
Criteria for inclusion in the study were:
Patients who had been treated with at least one dental implant in the area
of # 4-13 (maxillary central and lateral incisors, canines and first and second premolar
teeth) during the period January 1988 through July 2000.
Patients who had received the final fixed restoration, provided by UCHC
AEGD or Pros residents or faculty.
Patients whose final restorations were completed and functional at the
time of subject recruitment (May to August 2000).
Criteria for exclusion from the study were"
Patients who otherwise fulfilled the inclusion criteria, but whose final
restorations were provided by the investigators of this study.
All UCHC patients who received dental implants by UCHC AEGD or Pros
residents or faculty during the period January 1988 through July 2000 were identified
from procedure codes as they were entered to the UCHC dental finance computerized
records (IDX). Some of those codes were compliant with American Dental Association
(ADA) related codes, as listed in the ADA Current Dental Terminology (CDT-3) and
others were specific for UCHC (appendix B).
13
The identified dental records were reviewed by AL to further identify those
patients who met the inclusion criteria. For those patients who received more than one
dental implant in the area of interest (maxillary central and lateral incisors, canines and
first and second premolar teeth) only one implant was included in the study. For this
reason, the subjects were given specific instructions to evaluate and focus on the implant
restoration in their mouth, which had the most anterior (mesial) position (instructions in
cover letter, Appendix (2 and F)
Eligible patients (N=123) were subsequently mailed:
go
An introductory letter from the Director of the Graduate Prosthodontic
Program, which was introducing the investigator to the subjects, explaining the nature
and the purpose of the survey and encouraging them to participate (Appendix D).
No
A package, which included a cover letter (Appendix C), the questionnaire
itself (Appendix E) and a return addressed envelope.
Co
A second round was sent to the non-respondents, which included a cover
letter (Appendix F), the questionnaire and a return addressed envelope.
do
Thank you post-cards were sent to the respondents.
Each subject was assigned a study identification number, which was used in all
correspondence and analysis. The key list was maintained in a locked file, which was
accessible only by the principal investigators and which was only used for initial mailing
14
purposes. All analyses were conducted utilizing the assigned study identification number
and subjects’ identity remained confidemial.
Questionnaire
A 24-item self-administered multiple response questionnaire was mailed to the
subjects (Table 1). The questionnaire covered the subjects’ overall satisfaction with their
dental implant treatment, their perception of various technical aspects of their implant
restoration and selected demographic information.
Those treatment aspects include the following: a. appearance of the implant
restoration (shape, position, color), b. appearance of their gingiva (metal showing through
the gingiva, gingival recession, loss of interdental papilla), c. overall appearance of the
implant restoration when they smile, d. function (speech, chewing capacity, comfort), e.
oral health (ability to clean, freshness of breath, gingival inflammation), f. complications,
g. information they received about dental implants prior to their treatment, h. cost and
time until completion of treatment.
For each item the subjects rated their satisfaction on a 4-point Likert scale ranging
from, 1 being highly dissatisfied to 4, being highly satisfied or 1, strongly disagree to 4,
strongly agree.
15
Dental record review
Data abstraction (appendix G) from dental records of all eligible patients was
conducted by AL, who was blind to the questionnaire data for both subjects and non-
participants. The abstracted items (n=25) included the subjects’ age, gender, information
about the position of the implant replacing the missing tooth, proximity with other
restorations, chief complaint, duration of the treatment, type of implant placed, number of
missing teeth, type of interim restoration, whether a grafting procedure was performed,
presence of complications and history of psychological disorders.
STATISTICAL ANALYSIS
Overall patient satisfaction was considered to be the dependent variable and the
data abstracted from the dental records and the questionnaire were considered to be the
independent variables. The null hypothesis was that there was no statistically significant
difference between highly and less than highly satisfied patients in 1. patient perceptions
of specific technical aspects of treatment outcome e.g. appearance, function, oral health,
2. patient perceptions of treatment experience e.g. cost and time until completion of
treatment, satisfaction with treating doctor, 3. clinical variables related to dental implant
treatment, as abstracted from the dental records e.g. complications, length of treatment, 4.
patient demographic characteristics, such as age, gender, educational level, annual
income.
The chart and the questionnaire data were entered, by AL in Epi Info v.6.04c.
Statistical analyses were preformed, utilizing
SPSS v..10.1.
1. Descriptive statistics of demographic data were tested by t-test or Fisher’s
exact test for difference between the subjects and the non-participants.
2.
Frequencies were obtained to describe the response distribution of the
questionnaire and the dental record abstracted items.
16
3.
A large percentage (88%) of the subjects answered the overall satisfaction
question with the highest possible response. Because of the small number of responses in
the lower three categories, we chose to dichotomize the dependent variable into two
groups, highly and less than highly satisfied. The questionnaire and dental record
abstracted independent variables, likewise, had a generally skewed distribution with the
highest frequencies in the most favorable categories. For this reason they also were
dichotomized on their highest and "less than highest" levels. Fisher’s exact test was then
used .to screen the independent variables for a bivariate association with the defined
dichotomized overall satisfaction variable.
4. B ivariate odds ratios (OR) and. confidence intervals (CI) were produced by
unconditional logistic regression for the. dichotomized variables shown by Fisher’s exact
testing to be statistically significant at a level of p<0.05.
5. The statistically significant variables were then modeled by multivariate binary
logistic regression. A forward regression was conducted with variables entered by their
highest (absolute value) beta .parameter estimate.
RESULTS
Descriptive characteristics
The questionnaire was received from 62 subjects after the first mailing (50.4%). A
second round was mailed to the non-respondents and thank you post cards were sent to
17
18
the respondents. A total of 79 patients returned questionnaires following the second
mailing (total response rate 64%). One subject readdressed the return envelope to her
treating doctor and enclosed a note, complimenting him on the excellent quality of the
treatment and informing him of her ultimate satisfaction on all aspects of the prosthetic
result, but did not answer any of the questions. Two additional subjects answered
selectively part of the questionnaire and did not respond to the overall satisfaction
question. This effectively resulted in 76 respondents, who comprised the study’s analytic
sample. The questions that were not answered were treated as missing values in the
analyses.
As shown in Table 3, the subjects’ mean age was 56 years old, 43% of which
were below and 57% were above 56 years old, ranging from 18 to 80 years of age. 53%
of the subjects were women (n=42) and 47% men (n=37). 45 (58.4%) of the sample were
married and 32 (41.6%) were not currently married. This sample was highly educated
subjects as 77.9% had at least some college education. Forty-five percent had an annual
income of above $50.000.
Comparison between subjects and non-participants (Representation of sample)
Table 4 shows data abstracted from UCHC dental records of demographic and
selected other variables, comparing the study subjects and the questionnaire non-
respondents. T-test, and Fisher’s exact testing failed to demonstrate any statistically
19
significant difference for any variables, other than the variable "relation of treatment (Tx)
to chief complaint". The chief complaint
(CC) of the patients was recorded from an
existing form filled prior to the beginning of the treatment and the judgement was made,
by AL, on whether it was related or not to the dental implant treatment which was then
received. Of all identified potential participants, those patients whose chief complaint
was related to the dental implant were more likely to participate in the study (p=0.06).
Patient-satisfaction
The response distribution to the questionnaire items on patient satisfaction is
presented in Table 5. Sixty-seven (88.2%) of the subjects answered the overall
satisfaction question with the highest possible response ("highly satisfied"), eight
(10.5%), were "somewhat satisfied" and one (1.3%) was "somewhat dissatisfied" (Table
5).
The distribution of the responses to the questionnaire independent variables also
demonstrated limited variance within the four categories, as most responses were "highly
satisfied" or "satisfied" (Table 5).
More than 85% of the subjects were highly satisfied with the appearance of their
implant restoration (items Q2a, b, c). 90% of the subjects were satisfied with the
appearance of their gingiva (did not have cervical metal collar showing through and loss
of interdental papilla, items Q3 and 5). 80% of the subjects were highly satisfied with the
appearance of their implant restoration when smiling and 97% perceived their implant
20
restoration as equally attractive compared to their natural teeth (items Q6 and Q7). More
than 83% of the subjects were highly satisfied with the function of their implant
restoration (speech, chewing ability, comfort, items Q9a, b, c). 94% of the subjects were
satisfied with the oral health around their implant restoration and more than 95% were
satisfied with their ability to clean it and their freshness of breath (items Q 10a, b, c).
95% were satisfied with the amount of information they received about the procedure
prior to the beginning of the implant treatment (item Q 15) and almost 80% reported that
they believed the cost and time until completion of treatment was reasonable. 96%
would select an implant restoration if they had to do it again or would recommend it to a
friend (items 18a and b). Finally, all the subjects (100%) were satisfied with their
personal interaction with their treating doctor (item Q 19).
Specic aspects of dental implant treatment not related to overall satisfaction
Overall satisfaction was assessed bivariately, after dichotomizing both the
dependent and the independent variables on their highest and less than highest levels.
Fisher’s exact analyses were utilized to test for independence between overall satisfaction
and the questionnaire and data abstraction variables. The results are presented in Table 6
and Table 7, respectively. P-values were obtained by Fisher’s exact testing.
Table 6 shows that the color of the implant restoration (item 2c) was the only
"esthetic" variable, specific to the implant restoration, that was not related to overall
21
satisfaction at a statistically significant level (p=l.000). None of the questionnaire
variables which were describing satisfaction with the appearance of the soft tissues
around the dental implant (items 3-5), with oral health (items 10 a, b, c), the cost and time
(18a and b) until completion of treatment (items 17a and b) were significantly related to
overall satisfaction (Table 6). Factors, such as "who influenced your decision to select
dental implant treatment" (item 14) and "expense coverage" (item 16) and were also not
related to overall satisfaction at a statistically significant level.
Neither the demographic (age, gender, marital status, educational level, income),
nor any other variables (type, length, diameter of implant, smoking habits, history of
psychological disorder, complications) abstracted from the dental records were
statistically significant (Table 7). Data about the type of provisional restoration was
abstracted from the progress notes and the treatment planning sections of the dental
records. Due to the high percentage (51%) of subjects who had a removable treatment
partial denture (TxPD) for a provisional restoration, this variable was then dichotomized
and 1 was assigned to those who had a removable treatment partial denture and 0 to those
who had another type or no provisional restoration. Subjects who had a removable
treatment partial denture tended to be more satisfied with the final implant restoration
(p=0.074), as shown in Table 7.
22
Technical aspects and dimensions
of treatment bivariately
related to overall
satisfaction
The remaining 12 questionnaire variables demonstrated bivariate association
(Table 6) at a statistically significant level (p<0.05). Those included satisfaction with
appearance (items 2a, b 6 and 7, listed in Table 1), function (items 9a, b, c), satisfaction
with the treating doctor, information about the procedure and outcome prior to treatment
and finally, the presence of complications and the willingness to redo or recommend the
procedure. The distributions of the subjects’ responses in those questions are presented
in Table 5.
We chose to dichotomize the overall satisfaction dependent variable and the
independent variables because of the extremely skewed distributions. Bivariate odds
ratios were produced by unconditional logistic regression to assess the strength of
association, for the variables which were statistically significant by the exact test at a
level p-<0.05. The odds ratios (OR) and confidence intervals (CI) of those variables are
presented in the Table 9. OR and CI was also calculated for the variable "cost" (p=0.056,
as determined bivariately by Fisher’s exact testing), but it was not shown to be
significant. The odds ratios were then used to determine the sequence of inclusion of the
variables in a multivariate logistic regression model, the highest beta parameter estimate
(absolute value) being entered first. The final multivariate logistic regression model is
presented in Table 10. Variables that demonstrated a statistically significant relationship
23
with the patients’ self-reported overall satisfaction were the position and the shape of the
implant restoration.
The bivariate odds ratios of those variables are presented in the first column of
Table 9. Subjects who were highly satisfied with the position of their implam tooth were
more than 100 times more likely to be highly satisfied with their overall treatment
(CI =13-937), compared to less than highly satisfied patients. Patients who were highly
satisfied with the shape of their implant restoration were 55 times more likely to be
highly satisfied with their overall treatment (CI=8-357); patients who were highly
satisfied with their speech were 51 times more likely to be highly satisfied with their
overall treatment (CI=4-557), compared to less than highly satisfied patients etc. The
reason why the odds ratios of the independent variables are so large and the
corresponding confidence intervals are so wide is that in this study there are few "not so
highly satisfied" subjects (negative outcomes) and the sample size of the study is small.
Multivariate analysis
The final multivariate logistic regression model is presented in Table 10. Our
conclusions are that variables demonstrating a statistically significant relationship with
patient self-reported overall satisfaction were the position and the shape of the implant
restoration. As suggested by the odds ratios of those variables, patients who were highly
satisfied with the position of their implant tooth were 32 times more likely to be highly
24
satisfied with their overall treatment (CI=2.9-3 57), compared to less than highly satisfied
patients. Similarly, patiems who were highly satisfied with the shape of their implant
restoration were 12 times more likely to be highly satisfied with their overall treatment
(CI=I. 1-129.5), compared to less than highly satisfied patients. Additionally, although
not significant in the bivariate analysis, we controlled for age and gender, in a replicate
analysis of the multivariate model (Table 11), which produced essentially identical
results.
Ranking
Additionally to the questions utilized to examine association with overall
satisfaction with the treatmem result, in Q 13 (Table 12) the subjects were asked to list the
reasons, starting from the most important one, which led them to select an implant
restoration’ The responses to
this question were weighted by giving 3 points to each
subject’s first chosen factor, 2 points to the second and 1 point to the third. The points
were then summed for each factor to determine which was the most important one in the
patients’ decision to select the implant over other treatment alternatives, prior to the
beginning of the implant treatment. The results (presented in Table 12) demonstrate that
the primary reason why the subjects chose to proceed with the implant treatment was
their expectation of this type of treatment to be advantageous in terms of longevity.
Esthetic reasons are third in their preferences, after comfort and function is the fifth
25
reason, after the desire to preserve the structure of the teeth adjacent to the missing ones.
It is noteworthy that cost was the factor subjects seemed to be concerned with least.
Q12 (Table 13) provided descriptive information about subject preferences. 47
(59%) of the subjects responded that they would rather compromise appearance vs.
function in a hypothetical situation, whereas 24 (30%) would prefer to trade off function,
as long as the appearance of their implant prosthesis was perfect. Male subjects tend to
be more willing to compromise appearance vs. function than women, as demonstrated by
an OR=5.6 shown in Table 13
(CI=I.7-17.5).
Reliability issues
An attempt was made to assess the validity of this study by comparing dentists’
documentation with patients’ self-report of the complications, trying to establish criterion
validity with the dentist’s opinion as the gold standard. 15 subjects reported that they had
at least one complication in the corresponding questionnaire item (Q 11 Table 1), but
there was data in the dental records (A19 Table 2) describing complications for 11
patients. The questionnaire and dental record abstracted data are in agreement that there
was a complication, only in the case of 6 patients
(Table 14). A possible explanation for
this difference in the results may be that patients report symptoms, such as the pain
involved with the surgical part of the treatment as complications, particularly when they
had a bone graft, which may not have been documented in the progress notes and
26
therefore, not abstracted during the dental record review.
This finding suggests
limitations in some investigations relying, solely on dental record abstraction. There may
seem to be a conflict in this data; however, the ultimate judge who sets the gold standard
of what a complication is would not be the patient, but the treating doctor. Chi-square
analysis performed between those two variables showed that they are related to each
other at a statistically significant level, p=0.006 (Table 14). Also, the measure of
agreement, kappa, between those two variables was 0.354 and it was statistically
significant (p=0.002), which also reflects to the reliability of the instrument. If the same
variable is measured several times, a reliable instrument will record the same value, each
time it is measured. Interestingly enough, the variable derived from the questionnaire,
where subjects self-reported their complications (Table 6) was statistically significantly
related to overall satisfaction (p=0.001). This same variable examining complications
obtained by the dental record reviewed data (Table 7) did not relate
to
overall
satisfaction at a statistically significant level (p= 1.000).
The Cronbach’s alpha coefficient41-4 of the present questionnaire was 0.827,
which reflects an acceptable level of internal consistency reliability. This is a measure of
precision of the instrument, which implies how consistently a measurement can be
repeated on the same subjects43-44. All the variables that required responses rated 1
through 4 were included in this reliability analysis (n=21), i.e. Q2a-c, Q3-5, Q7-8, Q9a-c,
Q10a-c, Q15, Q17a,b, Q18a,b and Q19 (Table 1).
DISCUSSION
Dental implants have been established in the treatment of partial and complete
edentulism and have demonstrated high success rates, as judged by clinicians, based on
biologic and esthetic criteria. It has been stated9 that it is important to evaluate the
implant treatment from the patients’ standpoint as well, since they are the ultimate judges
of their restoration, in order to ensure their acceptance of the outcome and to address and
minimize potential areas of dissatisfaction in future treatment..The purpose of this study
was to determine whether there is an association between overall satisfaction with dental
implant treatment and 1. patient perceptions of selected technical aspects of treatment
outcome, 2. patient perceptions of treatment experience, 3. clinical variables related to
dental implant treatment, as abstracted from the dental records and 4. patient
demographic characteristics. Dental record abstraction and self-administered mailed
questionnaires were utilized to test the null hypotheses.
Overall patient-satisfaction
88% of the subjects were highly satisfied with the appearance of their implant
restoration.
These results are in agreement with previous studies. Chang et
a123
conducted a survey, where the patients were asked to mark their assessment on a 100-mm
line having end phrases "not at all satisfied" on the left and "completely satisfied" on the
fight, evaluating the appearance of their implant-supported single tooth replacement. The
27
28
subjects’ overall satisfaction, which was then measured to the nearest mm, was reported
as a percentage and it had a mean value of 94%. Avivi-Arber and Zarb4s used a
questionnaire with a 5-point scale to evaluate the esthetic outcome and reported that 88%
of their patients were satisfied. Carlson et al examined patient satisfaction using a
questionnaire, which was administered during patient recalls and reported that 83%
expressed satisfaction with their implant prostheses.
Demographic variables, technical aspects and dimensions
of the
scale not
related to overall satisfaction
In this study, no demographic variable was related to the overall satisfaction at a
statistically significant level. Vallittu et a146 stated, reporting the results of a survey, that
appearance was more important to women and younger patients, than men and older ones
and that patients with limited education had a greater preference for white teeth, than
patients with a higher educational level did. We were unable to demonstrate an
,
association between overall satisfaction and age, gender or educational level (Table 7).
Our results are in agreement with those of Kiyak et al2 and Chang et al
but not with
those of other reports24’ 46-47. One possible explanation for this difference may be that in
those studies patients assessed their dentition in general, while in the present study they
were asked to concentrate in evaluating only one implant restoration.
29
The variables concerning appearance of the soft tissues around the implant (Q3-5)
were also not significantly related to overall satisfaction. Porcelain fused to metal
implant-supported restorations may have a dark metal shade, as a result of improperly
positioned implant (inadequate depth) or of the implant material shade showing through
the soft tissues. The preservation of the papilla is an important issue, which influences
the appearance of the soft tissues around the implant restoration. As seen in Table 6,
50% or more of the subjects did have such problems, however those problems did not
affect their overall satisfaction with the appearance of their implant restoration. It is
possible that the patients had been informed of the problems and recognize the limitations
of the treatment or that they had tried to correct such problems with connective tissue
grafting or bone grafting to support the soft tissues48, as it is shown in Table 7, 40% of
the subjects had some bone or soft tissue grafting prior to, during or after the implant
surgery.
"Color" (shade) was the characteristic which best predicted the subjective
perception of dental attractiveness of a smile, as reported in a survey (N=297), conducted
by Dunn et a149 in 1996. It is surprising that we were unable to demonstrate a statistically
significant association, even at the bivariate level (Table 6). This may be due to the fact
that there were very few "negative" responses to this question. The reason for this may
be that the procedures particular to UCHC training programs lead to most subjects being
highly satisfied with the color of their implant restoration.
30
As it is shown in table 6, the subjects of this study were clearly dissatisfied with
both the cost and the time until completion of their treatment and the variable "cost"
approached (p=0.056) statistical significance as we defined it (p < 0.05). Moreover, as it
is demonstrated in Table 10, where subjects listed their preferences, cost is the least
important reason why they chose an implant vs. other alternative treatments. These
findings may suggest that patients do not find dental implant treatment inexpensive, but
those who finally decide to proceed with it are, more often, those who can actually afford
it. This statement is reinforced by the demographic characteristics, presented in Table 3,
where it is shown that 45% of the subjects had an annual income of more than $50,000.
As shown in Table 7, the type of provisional restoration used by 40% of the
subjects before the delivery of the final restoration was an interim removable treatment
partial denture. Subjects who had a treatment partial denture tended to be more highly
satisfied with their implant restoration (p=0.074). This removable prosthesis often
presents inadequate support and retention and may be apply excessive pressure, which
could traumatize the soft tissues and cause soft tissue recession or bone loss. Moreover,
this can be the type of prosthesis that the patients presented with and which they may
have been using to replace missing teeth for a longer period of time than just the implant
healing time.
This finding may suggest that when patients have had a previous
experience with a removable prosthesis, to compare their final implant restoration to,
31
which they may have had problems with, receive more favorably the final implant
restoration.
Technical aspects and dimensions
of scale bivariately
related to overall
satisfaction
The two variables that were statistically significant in the final multivariate
logistic regression model were "shape" and "position" of the implant restoration.
However, all the variables listed in Table 9 were related to overall patient satisfaction
with dental implant treatment at a statistically significant level in the bivariate analyses,
as demonstrated by Fisher’s exact testing, but they did not stay in the final model. It is
possible that any of these variables may have been shown to be predictors of overall
patient satisfaction, given a larger sample size. For the same reason, small sample size
and few negative ("less than highly satisfied") observations, the confidence intervals (CI)
in the logistic regression of these independent variables, as shown in Table 9, were wide.
The difference in proportion of "treatment which addressed the chief complaint"
over-"chief complaint unrelated to the dental treatment" between subjects and non-
participants (21/21 vs. 50/29, as shown in Table 4) had a p-value of 0.06. This may
suggest that the treating doctor may have encouraged non-participants to receive the
dental implant treatment, rather than addressing the patients’ primary concern
appropriately. This possible management failure may have led to dissatisfaction and
32
subsequent study response refusal. This negative finding suggests the importance of
patient-doctor communication that takes cognizance of patients concerns and perceptions.
The importance of addressing the patients’ chief complaint has also been recognized in
the complete denture literature 33’ 0-. Nassif et a133 in 1978, designed a self-administered
questionnaire as an aid to manage complete denture patients, consisting of 22 questions,
the first of which was "What is your chief complaint?"
Communication between the dentist and the patient is very important, in order to
achieve optimal esthetic results satisfactory to both, since these do not necessarily
coincide2. There is an increasing awareness of the importance of the patient-doctor
communication in achieving the desired health outcome 43’ 5-53 Boon et a143 obtained and
reviewed 44 instruments, developed from 1986 to 1996, which have been designed to
assess patient-doctor interactions. In this study, patients were asked if they were satisfied
with the amount of information they received prior to the beginning of the treatment. As
shown in Table 5, 69.3% of the subjects were highly satisfied with the amount of
information they received prior to their treatment, 25.3% were satisfied and 5.3% were
dissatisfied. The variable "information received prior to treatmem" was related to patient
overall satisfaction at a statistically significant level, as determined by Fisher’s exact
testing (p=0.003, shown in Table 6). This finding suggests that it is important to prepare
the patiems what to expect during each phase and from the final result of the treatment
and discuss with them treatment limitations that may apply to them. This may be
33
particularly necessary, especially when additional procedures e.g. autogenous grafting
from an extra-oral donor site or connective tissue palatal grafts are anticipated, which
may be the source of more severe pain and which may later affect their overall
satisfaction with the treatment outcome. Information about the appearance of the final
restoration may also be presented to the patient, prior to the beginning of the treatment by
means of a diagnostic wax-up. This can provide feedback and allow the patient to
approve the planned outcome, prior to committing to the treatment. By considering the
patients’ concerns and perceptions during initial the treatment-planning phase, the
rehabilitative dentist may increase the probability of successful outcomes.
67% of the subjects of this study strongly agree with the statement that they
would be willing to redo the same treatment, if they needed to and 68% would highly
recommend it to a friend (Table 5). These results seem to be in conflict with the
responses to the overall satisfaction (89%). It would be interesting to further investigate
the underlying reason why 89% of the subjects report highly on their overall satisfaction,
but only 67% would be very willing to repeat the treatment. Our results were slightly
lower, compared with those of a previous study45, where it was reported that 77% would
redo and 85% would recommend their dental implant treatment.
84% of the subjects are highly satisfied with their treating doctor and 16% were
satisfied (Table 5). The lack of negative responses to this question may be one of the
34
reasons why this variable, although significant bivariately (Table 9), was not significam
multivariately (Table 10). The importance of the "personality agreement" between
patiems and doctors has been reported by Levins4 in 1974, where it was suggested that
"in a patiem likes you, he’ll like your dentures".
Multivariate analysis
Our conclusions are that the variables position and shape of the implant
restoration are of primary importance in the patients’ ultimate satisfaction with the
overall dental implant treatment (Table 10).
Rehabilitative dentists have recognized the importance of a properly positioned
demal implant. This importance is also demonstrated by the application by surgeons of a
surgical guide, which is necessary in establishing the most appropriate surgical
placemem. In contemporary implant demistry, the position of the bone no longer dictates
implant placemem, as it did previously. Our findings are supported by those of previous
survey, conducted by Hawkins et al 5 in 1991. The authors examined patient satisfaction
with maxillary anterior fixed restorations and they reported that the levels of subjective
satisfaction are higher in class I ridges than in class II or III (p<0.05), according to the
classification of Siebert56 (appendix H). They concluded that ridge augmentation should
be considered, prior to the construction of maxillary anterior fixed prostheses,
particularly when class II or III defects are present.
Currently, several surgical
35
techniques are available to augment the implant site, in case ridge height or width is
inadequate. Bone grafting, as well as distraction osteogenesis is available to improve the
future implant sites and therefore, provide with optimum osseous sites for ideal
placement.
The presence of adequate ridge height and width has an impact on the contour
(shape) of the final restoration as well. The direction and extent of resorption in the
maxilla often results in situations where it is very difficult to achieve optimal esthetic
result, without augmentation procedures to correct the implant site ridge defects.
Compromising the contour of the final restoration and resulting in a "ridge lap" type
design is a common problem that occurs in restorations of the edentulous maxilla. This
design may often be the best way to deal with esthetic problems created by unfavorably
positioned implants. However, it does not always facilitate oral hygiene and it can be
responsible for plaque accumulation, which may cause tissue inflammation and
unpleasant mouth odor. The results of this study suggest that this may not only be a
potential area of dissatisfaction, but a predictor of overall satisfaction as well, as shown in
the final logistic regression model, retaining the implant position variable (Table 10).
36
Ranking
The subjects were asked to rank the reasons why they chose to have a dental
implant and what made them select this vs. other alternatives prior to the beginning of
treatment (Q-13, Table 1). The primary reason dental patients seem to state that they
select an implant over other treatment options is longevity (Table 12). The most frequent
cause of failure of tooth-supported fixed partial dentures is dental caries, as reported by
Walton et a157 and the mean length of service of all restorations is 8 years. They state that
dental caries affected 22% of the units that failed and led to the necessity for the
replacement of 24% of the units observed. Similar results were reported by Libby et al ss
who found that dental caries the most common cause of failure (38%) of fixed partial
dentures. Dental caries is obviously not a risk factor when the fixed partial dentures are
supported by dental implants and not by teeth. Therefore, from that aspect, dental
implants are advantageous vs. natural teeth in terms of longevity.
In the Q-12 where they were asked if they would rather compromise on their
esthetic appearance or their function in a hypothetical situation (Table 13), 59% would
choose function vs. 30%, who would prefer to have optimal esthetics. These results seem
to be in agreement with those reported in previous research3, where 62% of the subjects
(N=29) indicated a preference for function. However, the ranking scale used in this study
suggested otherwise. The third preferred reason for selecting an implant restoration was
esthetics and the fifth was function (Table 12). A possible explanation for this apparent
37
conflict in the subjects’ responses is that perhaps they report that they are more interested
in longevity and comfort (1 st and 2 nd selected factors, respectively), because this is what
they believe they are expected to respond and they don’t admit to their real primary
concern, which is esthetics. Another possible explanation for these results, given the high
percentages of subjects "highly satisfied" with the function of their implant restoration
(Table 5" Q9a-c), may be that once function has been restored, satisfaction with dental
treatment is related to esthetics.
It is interesting that there is a difference in gender, which is statistically
significant (p=0.002) in how the subjects answered question Q 12. Men are 5 times more
likely than women (OR=5.6) to be willing to compromise appearance vs. function if they
had to trade off. This difference in attitude between men and women and the orientation
of women towards esthetics has been reported before in the orthodontic literature 96,
regarding patients who choose to have orthognathic surgery. It has been stated that more
female than male patients proceed with the surgical treatment, because they wish to
change their appearance. On the other hand men are more likely to seek surgical
treatment in order to improve their function.
38
Limitations
There are several limitations to this study. The sample size was small (N=79) and
the selected patients were all treated in the UCHC, so the subject variance may have been
small. Variables that were not shown to be statistically significant may have influenced
the outcome, if the sample size was larger. The "negative" outcomes were few (low
frequencies of "less than highly satisfied" subjects, 11.8%). Additionally, the scale that
was used to categorize the responses was a 4-point Likert scale, which was not able to
create a wider variability in the response level. If that 4-point scale was replaced with a
scale, where the subjects had more options to choose from in their response, then the
dependent variable could be treated as an ordinal or as a continuous variable and that
design might facilitate the detection of an association relationship, given especially the
small sample size and the large number of independent variables. Such scales may be
1 a 10-point Likert scale 4 or 2. a simple linear analog self-assessment items (LASA),
validated in the psychometric literature 616. In the LASA format, subjects are requested
to place an x on a line, representing their preferences e.g. in a scale from 1 through 5,
with 1 being the most negative and 5 being the most positive outcome (visual analog
scales, VAS). Studies have indicated that VAS that use numeric anchors produce reliable
and accurate data62-63 similar to Likert scales.
Another limitation of this study was in the design of the self-administered mailed
questionnaire incorporating question 24 (appendix E). The income categories are
39
overlapping, so there is the probability of misclassification. Furthermore, the study was
retrospective and relied on subjects’ memory. Also, the data collected through the selfadministered questionnaire was subject to possible misinterpretations of the questions by
the subjects.
Future research
This initial work may be the foundation for developing a new scale, to measure
implant treatment "success", as perceived by the patients themselves. Our preliminary
findings are interesting; however there is limited ability to apply these results to the
general population. It would be necessary to administer this questionnaire to a larger
sample size and look at the psychometric properties of the scale more formally. For
example, factor analysis could then be performed to examine if these dimensions of the
scale really exist. By analyzing whether there is an underlying concept between specific
variables, there would be justification to categorize those variables in subscales and
eliminate through this process items that are not highly correlated.
Given the high level of patient overall satisfaction (89%) vs. 68% who highly
recommend this type of treatment and 67% who would be very willing to redo it, these
findings merit further research.
40
Conclusions
1. The variables "position" and "shape" of the implant restoration are the best
predictors of the patients’ self-reported overall satisfaction.
2. Other factors that demonstrated significance at the bivariate level may also be
important and truly associated with overall satisfaction, such as function (speech,
chewing capacity, comfort), appearance when smiling, similar appearance when
compared to natural teeth, satisfaction with the treating doctor, as well as absence of
complications during the treatment or amount of information received by the patient prior
to the beginning of the treatment.
3. Implant research on patient satisfaction may require a scale with expanded
response categories. This would result in a more sensitive scale to variations in
satisfaction.
4. Longevity, comfort and esthetics are factors highly correlated with the overall
satisfaction with the treatment outcome, but ultimately satisfaction with esthetics (shape,
position) is more important.
5. This questionnaire appears to be a reliable instrument, however further
research in this area is necessary.
6. Future research should address the measurement of dental implant treatment
"success", as perceived by the patients themselves.
41
These conclusions suggest that it is possible to determine patient centered
attributes conducive to implants, so that the outcome is successful judged by patient
criteria and that communication before and during the treatment and ultimate approval by
the patient of the shape and position of the final restoration are critical to ensure this
"success".
Table 1: List of items that appear in self-administered mailed questionnaire
1.
2.
6.
7.
8.
9.
10.
11.
12.
13.
Overall satisfaction with implant restoration
Satisfaction with appearance of implant restoration: a. Shape
b. Position
c. Color
Satisfaction with appearance of gingiva:
3. Dark metal shade showing through
4. Gingival recession (gums "shrank")
5. Loss of interdental papilla (gum between implant and tooth is dark)
Appearance when smiling
Appearance in comparison with natural tooth
Ability to distinguish between implant and natural tooth
Satisfaction with function of implant: a. Speech
b. Chewing capacity
c. Comfort
Satisfaction with oral health: a. Cleansing ability
b. Freshness of breath
c. Gingival inflammation
Complications during treatment
Trade off: appearance vs. function
Reasons for electing dental implant over other alternative treatments prior to beginning of
treatment
14. Who influenced decision to select dental implant
15. Information about dental implant received prior to beginning of treatment
16, ..E.xpenses covered by third party
17. A-If cost was reasonable
B-If time until completion of treatment was reasonable
18. A-Would you recommend the treatment
B-Would you redo the treatment
19. Satisfaction with treating doctor
20. Feelings about your own facial attractiveness
21. Marital stares
22. Education
23. Occupation
24. Annual income
42
43
Table 2: List of variables that appear in the dental record data abstraction form
A2.
A3.
A4.
A5
A6.
Age
Gender
Previous implant failure
Profession
Chief complaint
A7,8. Length of treatment
A9. Restorative dentist
A10a. Implant location
A10b. Adjacent teeth restored
A 11 a. Implant company of implant placed
A 11 b. 15 implant
A
1,
,-,/1,/;,-, .,1,-,
A 12a.Length of implant placed
A 12b.Diameter of implant placed
A13. Number of teeth present
A15. Type of provisional
A16. Bone graing
A18. Smoking
A19.
A21.
A22.
A23.
A25.
Complicaions
Health history
Medicaion
Histo of psychological disorder
Insurance coverage
44
Table 3" Demographic characteristics of subjects (n=79)
Age (79)
35 and under
36-45
46-55
56-65
Over 65
8
13
13
20
25
(10.1)
(16.5)
(16.5)
(25.3)
(31.6)
Gender (79)
Male
37 (46.8)
f E;IIIizllE;
.z .jj
Marital Status (77)
Single
Divorced
Widowed
Married
Educational Level (76)
8th grade or less
Some high school
Graduated high school
Some college
Graduated college
More than college
Annual Income (65)
Less than $10,000
$10,000-25,000
$25,000-50,000
$50,000-100,000
$100,000 or more
19 (24.7)
9 (11.7)
4 (5.2)
45 (58.4)
3 (3.9)
(.3)
12(15.8)
21 (27.6)
20 (26.3)
19 (25)
5
11
19
19
11
(7.5)
(16.4)
(28.4)
(28.4)
(16.4)
45
Table 4- Comparison between subjects and non-participants
Mean Age
53.34
56.13
Gender
Female
Male
25
19
42
37
0.710"*
1.000"*
Complications
No
Yes
35
9
66
13
0.758**
Previous Implant Failure
No
Yes
19
1
39
1
21
21
29
50
480
440
Relation of TxI to CC III
No
Yes
Mean length of Tx (days)
0.06**
* t-test
**Fisher’s exact test
complications, as reported in progress notes
ii
Tx." treatment
CC: chief complaint
izz
0.31 *
0.408*
46
?
:::::::::::::::::::
..;,v,.....v.::::::::
::::::::::::::::::::::
::::::::::::::::::::::
::::::::::::::::::::::
o
;;;
b
..-.-.-.?.-..--?..?..-...
::::::::::::::::::::::
:::::::::::::::::::::::
::::::::::::::::::::
::::::::::::::::::::
"-
=
47
::::i::.:i:
:i:::i:i:i:
iii,:.:.:.:.:.....
o
o
0
o
o
o
o
o
n
0
o-
o
0
o
0
48
:::::::::::::::::::::::::
::::::::::::::::::::
::. ....:?::
:::::::
:::::::::::::::,.::::::::::::::::
::::::::::::::::::::::::::
5O
:::::::::::::::::::::::::::::::
51
52
.N. . . . . . . . . . . .
0
c
c
53
54
Table 8 (summarized)" Questionnaire and dental record variables that were not related to
patiem overall satisfaction (p>0.05)
Color
Metal shade showing through
Gingival recession
Loss of interdental papilla
Cannot distinguish from natural teeth
Q 10a. Ability to clean
Q 10b. Freshness of breath
Q 10c. Health of gums around the implam
Q 14. Decision influenced by third person
Q 17a. Cost
1 u. me um, uumpcuu,, of Tx
Q21. Marital stares
Q22. Educational level
Q24. Annual income
Q2c.
Q3.
Q4.
Q5.
Q8.
A2.
A3.
A4.
Age
Gender
Previous implant failure
A5. Immediate implant
A6. Treatment related to CC
A9. Restorative dentist
A10a. Implant location
A10b.Adjacent teeth also restored
A 1 a. Implant company
A 11 b. 15 implant
A11 c. Esthetic plus implant
A 12a. Length of implant placed
A 12b. Diameter of implant placed
A13. Number of presem teeth
A15. Type of provisional restoration
A16. Grafting
A18. Smoking
A19. Complications
A23. History of psychological disorder
* as determined by Fisher’s exact testing
1.000
0.711
1.000
1.000
0.284
0.135
1.000
1.000
1.000
0.056
o_.0
0.7
0.3
1.000
1.000
0.481
1.000
1.000
0.472
1.000
0.284
0.316
1.000
1.000
1.000
0.147
1.000
1.000
0.074
0.728
0.764
1.000
1.000
55
Table 9" Bivariate odds ratios and CI’s of questionnaire variables that were related to
patient overall satisfaction as determined by Fisher’s exact testing at a statistically
significant level p<0.05
Q2a.
Q2b.
Q6.
Q7.
Q9a.
Q9b.
Q9c.
Shape
Position
Appearance when smiling
Comparison with natural teeth
Speech
Chewing capacity
Comfort
,,II ’-’’’’""*"-"
Q 15. Information prior to Tx
Q 18a. Would redo treatment
Q 18b. Would recommend Tx
Q19. Satisfaction with doctor
4
4.7
3.5
1.7
3.9
2.9
2.8
2
2.3
3.1
3.2
2.3
55.1
113.7
35.5
5.8
51.9
20
16.7
!4.2
10.7
24.4
26.6
10.3
8.5-357
13.7-937.4
5.9-211.2
1.1-30.4
4.8-557.6
3.9-101
2.9-96.8
2.9-68.5
2-56.9
2.8-210.6
3-230
2.2-47.8
0.000
0.000
0.000
0.036
0.001
0.000
0.002
0.00!
0.005
0.004
0.003
0.003
56
Table 10: Final multivariate logistic regression model for overall satisfaction
Position
3.4
32.6 (2.9-357)
0.004
Shape
2.5
12.3 (1.1-129.5)
0.036
57
Table 11: Final multivariate logistic regression model, after controlling for age and
gender
Position
3.7
42 (2.7-644.1)
0.007
Shape
Age
2.3
10.3 (0.8-127.1)
0.069
-0.04
0.9 (0.4-2.2)
0.924
Gender*
-0.8
0.4 (0.3-5.5)
0.526
*referent category: females
58
Table 12" Q 13- Reasons to select dental implant over other alternatives prior to treatment
Longevity/
less need for repair
Comfort
Esthetics: look better
Preservation of natural
teeth adjacent to missing
1 st
2nd
3rd
20
9
11
10
17
12
12
15
14
92
76
71
ones
Function:
4th
10
12
13
67
chew/speak better
5th
6th
7th
9
10
2
3
74
12
9
1
1
74
9
9
2
0
60
57
10
11
Oral health
Cost
Other: please specify
Total:
74
* The responses to this question were weighted by giving 3 points to each subject’s first selected
factor, 2 points to the second and 1 point to the third. The points were then summed for each
factor
to determine which was the most important one in the patients decision to select the
implant over other treatment alternatives
59
Table 13: Q 12-Trade off; would rather compromise appearance vs. function (%)
Appearance
47 (59)
19
28
Function
24 (30)
19
5
*Referent category: females
0.002
5.6* (1.7-17.5)
60
Tble 14: Chi-square analysis and measure of agreement (kappa) between the two
variables examining complications. Q11, which was derived from the questionnaire,
describes what the subjects perceived as a complication, whereas A19 is the data as
abstracted by AL from the dental records
Q11: Subjectreported
complications
No
Yes
No
Yes
56
9
5
6
k=0.354
p=O.O06
p=O.O02
Appendix A" Measure of dental patient satisfaction
1. Access
2. Availability/convenience
3. Cost
4. Pain
5. Quality of care
1. Access
2. Availability
3. Facilities
4. Patient waiting time
5. Cost
6. Pain
7. Technical quality of care
8. Staff technical quality of care
9. Staff-patient relations
I0 lf;f f;nf relf;nc
11. Continuity
12. Auxiliaries performing expanded duties
13. Office atmosphere
61
62
Appendix B: Procedure codes used to identify potential subjects
6010
16010
21248
06020
12760
02750
02740
06750
Surgical placement-endosteal implant
Surgical placement-endosteal implant-additional
Reconstruction maxillary/mandibular with implants
Abutment placement-endosteal implant
Implant crown
Crown porcelainigh noble metal
Crown porcelain/ceramic substrate
Bridge crown porcelain/high noble metal
D6010
D6020
D2750
D2740
D6750
63
Appendix C: Cover letter, which accompanied questionnaire during first mailing
Dear
The purpose of this letter is to ask your support with a study that we are
conducting at the University of Connecticut Health Center regarding our patients’
satisfaction with their dental implant treatment. As an eligible implant patient you are
invited to participate in this study. Your help by completing and returning this
questionnaire is of value to us and will be greatly appreciated.
The enclosed
questionnaire should take you approximately 15-20 minutes to complete.
The purpose of this survey is to gather information that only you can provide from
your own experience and about your personal perception of specific aspects of dental
implant treatment. We have limited this questionnaire only to certain aspects of your
implant treatment that are related to specific research questions. Please, understand that
should you agree to participate, you will receive no direct benefit. Your response will be
applied in the future to improve the quality and results of dental implant care and overall
satisfaction.
Your identity will remain absolutely confidential. An idemification number will
be assigned to each questionnaire that will be used instead of your name for idemification
purposes and no patient will be identified by name. All correspondence and analyses will
be conducted with that assigned idemification number, therefore linking your name with
your response will not be possible, other than by the primary investigators for this initial
contact. Our receipt of this completed questionnaire will provide us with your informed
consem for this survey.
64
Should you have any inquiries about this questionnaire or any other aspect of the
research, you can contact me at (860) 679-2659.
If you have any questions regarding your rights as a research subject or need any
additional information, you may contact an Institutional Review Board (IRB)
Representative at (860) 679-3054.
Please, return the completed enclosed questionnaire in the envelope provided.
Thank you for your time and effort.
Your contribution to this project is deeply appreciated.
Sincerely yours,
Ana Levi, DDS
Annika Levi, DDS
Ifyou have more than one dental implant, please answer these questions in
respect to the implant that is in the upper most_front position, closer to the
center o_fyour smile.
65
Appendix D: Introductory letter sent by the Director of the Graduate Prosthodontic
Program
Dear
The purpose of this letter is to request your help with a survey to assess patients’
perceptions regarding dental implant treatment. This study is being conducted by one of my
outstanding graduate students, Dr Annika Levi. We anticipate that her findings will improve
patient care. All the patients who have received dental implant restorations for their front teeth at
the University of Connecticut from Jan 1992 until Dec 1999, are being invited to participate. The
questionnaire you will be sent should take you approximately 15-20 minutes to complete. All
responses received will be coded and kept anonymous and confidential.
Each respondent is very important to this study. Your personal opinion may be critical in
our evaluations.
Dr. Levi will be sending you the questionnaire within two weeks of your having received
this letter. The staff and I, at the UCHC thank you for your support and contribution.to this project.
Truly yours,
John R. Agar, DDS, MA
Director of Graduate Prosthodontics
66
Appendix E" Self-administered mailed questionnaire
PATIENT
SATISFACTION
WHAT IS IMPORTANT?
A STUDY OF PATIENTS’ ASSESSMENT OF THEIR DENTAL
IMPLANT TREATMENT
Department of Prosthodontics and Operative Dentistry
University of Connecticut Health Center
Farmington, Connecticut
67
The questions that follow ask for your opinion about the implant treatment you have
received at the University of Connecticut Health Center. The purpose of these
questions is to gain an understanding of the degree of your satisfaction regarding the
appearance, comfort, chewing capacity, hygiene, maintenance and cost of your
implant restoration. Generally speaking, we are interested in aspects YOU consider to
be important in dental implant treatment. In order to allow us to improve our services
please, make sure that you answer all the questions.
If,Fou have more than one dental implant please answer these questions in respect
to the implant that is in the upper most [ront position closer to the center of Four
smile.
68
(Pt
ID
SATISFACTION FROM DENTAL IMPLANT TREATMENT
(Please, clearly check (,/) only one choice in the box provided under the answer that best
represen your opinion for each question)
Q-1 In general, how satisfied are you
with your implant restoration?
HIGHLY
SATISFIED
SOMEWHAT
SATISFIED
SOMEWHAT
DISA TISFIED
L_J
HIGHLY
DISA TISFIED
"1
While the previous question asked about your overall impression about your implan
restoration, the following questions will ask you about specific aspects of your treatmen
experience.
Please pay careful attention to the underlined words.
APPEARANCE (ESTHETICS)
Q-2 How satisfied are you with the appearance of your implant restoration in regards to:
HIGHLY
SATISFIED
SOMEWHAT
SATISFIED
SOMEWHAT
DISA TISFIED
HIGHLY
DISATISFIED
a. shape of the implant tooth
b. the position of the implant tooth in
relation to the teeth next to it
I"
c. the color of the implant tooth
S TR ONGL Y
AGREE
AGREE
LJ
DISAGREE
LJ
S TR ONGL Y
DISAGREE
Q,-3 1 have dark metal shade showing through
my gums near the implant
Q-4 My gums have shrunk around my implant
tooth
Q-5 The gum between my teeth and the
implant tooth is dark
HIGHLY
SATISFIED
Q-6 How do you feel about the appearance of
your implant tooth when you smile
SOMEWHAT
SA TISFlED
SOMEWHAT
DISA TISFlED
HIGHLY
DISA TISFIED
69
(Please, check (,/) in the box under the one best answer and proceed to the next question as
indicated)
S TR ONGL Y
AGREE
AGREE
DISAGREE
S TR ONGL Y
DISAGREE
Q-7 The appearance of my implant tooth is
equally attractive as my natural teeth.
Proceed directly to 0,-8
Answer Q- 7a
Q-7a Which is more attractive, your implant restoration or your own teeth ?
(Please, cheek (vz) next to your answer)
IMPLANT TOOTH
NATURAL TOOTH
S TR ONGL Y
AGREE
AGREE
DISAGREE
STR ONGL
DISAGREE
SOMEWHAT
DISA TISFIED
HIGHLY
DISA TISFIED
Q-8 You cannot tell the difference between
the implant tooth and your own teeth
FUNCTION
Q-9 How do you feel about the function of your implant tooth as regards to"
HIGHLY
SATISFIED
SOMEWHAT
SATISFIED
a. speech/ pronouncing words
b. ability to chew different foods
c. comfort
ORAL HEALTH
Q-10 How do you feel about the following aspects of oral cleanliness related to your implant tooth as
regards to:
HIGHLY
SATISFIED
SOMEWHAT
SATISFIED
SOMEWHAT
DISA TISFIED
HIGHLY
DISA TISFIED
a. ability to clean around your implant
b. freshness of breath
c. health of your gums around the
implant
L
70
COMPLICATIONS/REPAIRS
Q-11 Did you have any complications with your implant treatment?
(Please, check (,/) the one best answer and proceed to the next questions as indicated)
NO
YES
please, skip to Q-12
please answer Che following 3 questions
Please specify what the problem was:
11 a. How many visits did it take to fix this problem?
ONLY ONE
2-3
MORE THAN 4
STILL NOT FIXED
1 lb. How serious was the problem?
NOT A TALL SERIOUS
SOMEWHATSERIOUS
SERIOUS
VERY SERIO US
11c How much did this problem affect your overall satisfaction?
NO TA T ALL
SOMEWHAT
SERIOUSLY
VERY SERIOUSL Y
Q-12 It is ideal to have an implant restoration that both looks good and functions well.
However, if you had to make a trade off, what would you prefer to give up?
(Please, indicate your choice by checking ( ’) in the box next to the statement that best
represents you)
I would be more willing to compromise the appearance of my restoration, as long as my
ability to bite into different foods (chewing) was perfect.
I would be more willing to accept a lower chewing level, as long as the appearance of my
restoration was perfect.
-
71
Q-13 While in the previous question Q-12 we asked you about the current opinion of your implant
restoration you have now, we would like to ask you about the way you felt at the time you made the
decision to have your implant.
Which of the following factors were more important to YOU personally back then in deciding te
have implant instead of alternative treatment, such as fixed bridgework or removable dentures?
(Please, rank the three factors that made you select implants over all other options)
FACTORS
Cost: cheaper
1.
2.
3.
4.
5.
Oral health
Comfort
Longevity/less need for repair
Function: chew/speak better
U.
laCllKPLlt,..,S" IUuI%S
UKJLLE:::;I
7. Preservation of natural teeth
adjacent to missing ones
8. Other"
Factor
RANK
Number
1 st most important
2 na most important
3 ra most important
Please, specify
Q-14 Who influenced your decision to have an implant restoration?
1. Family/friend
2. My dentist
3. My own decision
Q-15 How do you feel about the information you had about the implant treatment before you received
your implant? (i.e. information about your surgery, prosthetic restoration, overall time needed until
completion of treatment, cost etc.)
HIGHLY SATISFIED
SOMEWHAT
SATISFIED
SOMEWHAT
DISA TISFIED
HIGHLY
DISA TISFIED
72
Q-16 Who covered the expenses for your implant treatment?
Please indicate what percentage of your implant treatment was covered by each payment source.
(Please be sure that the percents you write down totals 100%)
1. Self pay
2. Third party pay / Dental Insurance
3. Government plan
4. Research participant
Total
%
%
%
%
+
+
+
100%
Q-17 How strongly do you agree or disagree with the statement that:
S TR ONGL Y
AGREE
AGREE
a. the cost of your implant treatment
was reasonable?
b. your implant was completed in a
reasonable time?
DISAGREE
S TR ONGL Y
il
Q-18 Considering the current level of your overall satisfaction as well as the cost and the time it took to
complete this treatment, please answer the following 2 questions"
(Please, check (/’) your answer)
S TR ONGL Y
AGREE
18a. I would select an implant
restoration if I had to do it all over
again
18b. I would recommend an implant
restoration to a friend
LJ
II
HIGHLY
SA TISFlED
Q-19 In general, how satisfied were you
from your personal interaction with
your treating doctor?
AGREE
DISAGREE
S TR ONGL Y
DISAGREE
/
II
SOMEWHAT
SATISFIED
II
SOMEWHAT
DISA TISFIED
II
HIGHLY
DISA TISFIED
73
Q-20 Now, we would like to ask you some questions about your present feelings regarding your facia
attractiveness. This question is about your whole face, not just about your implant.
(Please, consider each item below and check (,/) in the box which best represents your feeling,
about yourself at the present time)
Consider
myself very
fortunateI love it
I am
satisfied
No
particular
feelings one
way or the
other
1. Hair
2. Ears
3. Forehead
4. Eyes
5. Eyebrows
6. Nose
7. Cheeks
8. Lips
9. Mouth
10. Teeth
11. Smile
12. Chin
13. Facial complexion
14.Neck
15.Profile
16. Overall facial
attractiveness
Last we would like to ask you some information about yourself."
Q-21 What is your current marital status?
(Please, check)
Single
Divorced
Separated
2 l a. Are you currently living:
With a spouse/partner
Alone
Married
With a friend/family
Don’t like
Strong
but can put
up with
negative
feelingsI hate it
74
Q-22 What is the highest grade or year of school you have completed?
(Please, eheek one best answer)
8 th grade or less
Some high school
Graduated high school
Some college
Graduated college
More than college
Q-23 What is your usual occupation?
Q-24 Which of the following categories best describes your yearly household income from all sources for
1999?
(Please, be sure to indicate the total household income for 1999, not just your personal income)
Less than $10,000
$10,000 $25,000
$25,000-50,000
$50,000-100,000
$100,000 or more
I don’t know
Is there anything we may have overlooked? Please use this space for any additional comments you
would like to make.
l’hank you for your helt and time.
If you would like a summary of the overall results, please print your name and address on the back
of the returned envelope. We will make sure that you will receive a copy of the results within 4
months of the completion of the survey.
75
Appendix F: Cover letter, which accompanied questionnaire, during the second mailing
Dear
You should already have received in the mail a package from the Graduate
Prosthodontic Clinic at the University of Connecticut Health Center.
The purpose of this letter is to ask again for your support with a study that we are
conducting regarding our patients’ satisfaction with their dental implant treatment. As
an eligible implant patient you are invited to participate in this study. Your help by
completing and returning this questionnaire is of value to us and will be greatly
appreciated. The enclosed questionnaire should take you approximately 15-20 minutes to
complete.
The purpose of this survey is to gather information that only you can provide from
your own experience and about your personal perception of specific aspects of dental
implant treatment. We have limited this questionnaire only to certain aspects of your
implant treatment that are related to specific research questions. Please, understand that
should you agree to participate, you will receive no direct benefit. Your response will be
applied in the future to improve the quality and results of dental implant care and overall
satisfaction.
Your identity will remain absolutely confidential. An idemification number will
be assigned to each questionnaire that will be used instead of your name for identification
purposes and no patient will be identified by name. All correspondence and analysis will
be conducted with that assigned identification number, therefore linking your name with
your response will not be possible, other than by the primary investigators for this initial
contact. Our receipt of this completed questionnaire will provide us with your informed
consent for this survey.
76
Should you have any inquiries about this questionnaire or any other aspect of the
research, you can contact me at (860) 679-2659.
If you have any questions regarding your rights as a research subject or need any
additional information, you may contact an Institutional Review Board (IRB)
Representative at (860) 679-3054.
Please, take the time to complete the enclosed questionnaire and return it in the
envelope provided.
Thank you for your time and effort.
Your contribution to this project is deeply appreciated.
Sincerely yours,
A rra Levi, DDS
Annika Levi, DDS
Ifyou have more than one dental implant, please answer these questions in
respect to the implant that is in the upper most.frontposition, closer to the
center ofyour smile.
77
Appendix G: Dental record review data abstraction form
Data abstraction form
1. STUDY ID:Pt
2. AGE
MALE
4. DATE OF SURGERY:
3. GENDER:
/
FEMALE
5. Profession:
6. CHIEF COMPLAINT:
7. START DATE:
/
8. END DATE:
/
/
FACULTY
9. RESTORATIVE DENTIST: RESIDENT
10. POSITION OF
IMPLANT(S) PLACED:
4
5
6
7 8 9
10
11
12
13
11. TYPE OF IMPLANT PLACED:
a. ITI
b. NOBEL BIOCARE
12. LENGTH:
13,
No OF PRESENTTEETH:
14 TIME EDENTULOUS BEFORE Tx:
15 RESTORATION BEFORE Tx:
15a INTERIM PD (FLIPPER)
15b RESIN BONDED FPD
15c RPD
c. Other"
/
78
16. BONE GRAFTING
a. PRIOR to, implant surgery
b. DURING implant surgery
c.
AFTER implant surgery
17. If grafting procedure was performed:
1. Autogenous (tibia, iliac, chin, tuberosity)
2. DBFBA
3. Bio-os
4. Mixture of autogenous w/other
5. Soft tissue grafting
18. SMOKING:
NO
YES
lo
LESS THAN 5 cigarettes/day
5 cigarettes- 1 pack/day
go
MORE THAN 1 pack/day
79
19. COMPLICATIONS
A. SURGICAL
times
duration
unresolved
DATE*"
1. Anesthesia/2.Paresthesia
/
/
3. Injury of adjacent tooth
/
/
4. Infection
/
/
5. Implant loss
/
/
6. Other:
/
/
B. PROSTHETIC
times
duration
unresolved
DATE*
1. Abutment/occlusal screw loosening
/
/
2. Abutment/occlusal screw fracture
/
/
Abscess formation
/
/
4. Porcelain fracture
/
/
5. Resin/denture tooth fracture
/
/
7. Other:
/
/
3.
*of last occurrence, if same complication more than once
20. NUMBER OF VISITS INVOLVING COMPLICATION:
21. HEALTH HISTORY:
22. MEDICATION:
80
23. POSITIVE HISTORY FOR PSYCHOLOGIC DISORDER: Y
24. MEDICATION
a. ANTI-ANXIETY:
b. ANTI-DEPRESSANT:
c. ANTI-PSYCHOTIC:
d. OTHER:
25. INSURANCE:
Self Pay
State
Welfare
Other
N
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